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Study Cites Toll of AIDS Policy in South Africa

A Johannesburg AIDS hospice in 2002. From 2000 to 2005, few South Africans got the AIDS drugs they needed, a study found.Credit
Joao Silva for The New York Times

JOHANNESBURG — A new study by Harvard researchers estimates that the South African government would have prevented the premature deaths of 365,000 people earlier this decade if it had provided antiretroviral drugs to AIDS patients and widely administered drugs to help prevent pregnant women from infecting their babies.

The Harvard study concluded that the policies grew out of President Thabo Mbeki’s denial of the well-established scientific consensus about the viral cause of AIDS and the essential role of antiretroviral drugs in treating it.

Coming in the wake of Mr. Mbeki’s ouster in September after a power struggle in his party, the African National Congress, the report has reignited questions about why Mr. Mbeki, a man of great acumen, was so influenced by AIDS denialists.

And it has again caused soul-searching about why his colleagues in the party did not act earlier to challenge his resistance to broadly accepted methods of treating and preventing AIDS.

Reckoning with a legacy of such policies, Mr. Mbeki’s’s successor, Kgalema Motlanthe, acted on the first day of his presidency two months ago to remove the health minister, Manto Tshabalala-Msimang, a polarizing figure who had proposed garlic, lemon juice and beetroot as AIDS remedies.

He replaced her with Barbara Hogan, who has brought South Africa — the most powerful country in a region at the epicenter of the world’s AIDS pandemic — back into the mainstream.

“I feel ashamed that we have to own up to what Harvard is saying,” Ms. Hogan, an A.N.C. stalwart who was imprisoned for a decade during the anti-apartheid struggle, said in a recent interview. “The era of denialism is over completely in South Africa.”

For years, the South African government did not provide antiretroviral medicines, even as Botswana and Namibia, neighboring countries with epidemics of similar scale, took action, the Harvard study reported.

The Harvard researchers quantified the human cost of that inaction by comparing the number of people who got antiretrovirals in South Africa from 2000 to 2005 with the number the government could have reached had it put in place a workable treatment and prevention program.

They estimated that by 2005, South Africa could have been helping half those in need but had reached only 23 percent. By comparison, Botswana was already providing treatment to 85 percent of those in need, and Namibia to 71 percent.

The 330,000 South Africans who died for lack of treatment and the 35,000 babies who perished because they were infected with H.I.V. together lost at least 3.8 million years of life, the study concluded.

Epidemiologists and biostatisticians who reviewed the study for The New York Times said the researchers had based their estimates on conservative assumptions and used a sound methodology.

“They have truly used conservative estimates for their calculations, and I would consider their numbers quite reasonable,” James Chin, a professor of epidemiology at the University of California at Berkeley’s School of Public Health, said in an e-mail message.

The report was posted online last month and will be published on Monday in the peer-reviewed Journal of Acquired Immune Deficiency Syndromes.

Max Essex, the virologist who has led the Harvard School of Public Health’s AIDS research program for the past 20 years and who oversaw the study, called South Africa’s response to AIDS under Mr. Mbeki “a case of bad, or even evil, public health.”

Mr. Mbeki has maintained a silence on his AIDS legacy since his forced resignation. His spokesman, Mukoni Ratshitanga, said Mr. Mbeki would not discuss his thinking on H.I.V. and AIDS, explaining that policy decisions were made collectively by the cabinet and so questions should be addressed to the government.

The new government is now trying to hasten the expansion of antiretroviral treatments. The task is urgent. South Africa today is home to 5.7 million people who are H.I.V.-positive — more than any other nation, almost one in five adults. More than 900 people a day die here as a result of AIDS, the United Nations estimates.

Since the party forced Mr. Mbeki from office and some of his loyalists split off to start a new party, rivalries have flared and stories about what happened inside the A.N.C. have begun to tumble out, offering unsettling glimpses of how South Africa’s AIDS policies went so wrong.

From the first year of his presidency in 1999, Mr. Mbeki became consumed with the thinking of a small group of dissident scientists who argued that H.I.V. was not the cause of AIDS, his biographers say.

As president he wielded enormous power, and those who disagreed with him said they feared they would be sidelined if they spoke out. Even Nelson Mandela, the revered former president, was not immune from opprobrium.

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In a column in The Sunday Times of Johannesburg on Oct. 19, Ngoako Ramatlhodi, a senior party member now running the party’s 2009 election campaign, recounted how Mr. Mandela, known affectionately as Madiba, was humiliated during a 2002 A.N.C. meeting after he made a rare appearance to question the party’s stance on AIDS.

Mr. Ramatlhodi himself acknowledged in a recent interview that in 2001 he sent a 22-page letter, drafted by Mr. Mbeki’s office, to another of Mr. Mbeki’s most credible critics, Prof. Malegapuru Makgoba, an immunologist who was one of South Africa’s leading scientists. The letter accused Professor Makgoba of defending Western science and its racist ideas about Africans at the expense of Mr. Mbeki.

In 2000 Mr. Mbeki had provided Professor Makgoba with two bound volumes containing 1,500 pages of documents written by AIDS denialists. After reading them, Professor Makgoba said in an interview that he wrote back to warn Mr. Mbeki that if he adopted the denialists’ ideas, South Africa would “become the laughingstock, if not the pariah, of the world again.”

But Mr. Mbeki indicated last year to one of his biographers, Mark Gevisser, that his views on AIDS were essentially unchanged, pointing the writer to a document that, he said, was drafted by A.N.C. leaders and accurately reflected his position.

The document’s authors conceded that H.I.V. might be one cause of AIDS but contended that there were many others, like other diseases and malnutrition.

The document maintained that antiretrovirals were toxic. And it suggested that powerful vested interests — drug companies, governments, scientists — pushed the consensus view of AIDS in a quest for money and power, while peddling centuries-old white racist beliefs that depicted Africans as sexually rapacious.

“Yes, we are sex crazy!” the document’s authors bitterly exclaimed. “Yes, we are diseased! Yes, we spread the deadly H.I. virus through our uncontrolled heterosexual sex!”

In 2002, after a prolonged outcry over Mr. Mbeki’s comments about AIDS and the government’s policies, Mr. Mbeki agreed to requests from within his party to withdraw from the public debate. That same year, the Constitutional Court ruled that the government had to provide antiretroviral drugs to prevent the infection of newborns. And in 2003, the cabinet announced plans to go forward with an antiretroviral treatment program.

“We did an enormous amount of good in the early days in South Africa, not because of the Health Ministry, but in spite of the Health Ministry,” said Randall L. Tobias, who was appointed by President Bush in 2003 to lead the United States’ $15 billion global AIDS undertaking.

In the same years, former President Clinton and his foundation were also deeply involved in helping South Africa get a treatment program going. Mr. Clinton attended Mr. Mandela’s 85th birthday celebration in Johannesburg in 2003. During the dinner, he and Mr. Mbeki slipped away to talk about AIDS, Mr. Clinton recalled in a recent interview.

Mr. Clinton said he told Mr. Mbeki how antiretroviral treatment had reduced the AIDS mortality rate in the United States and reminded him, “I’m your friend and I haven’t joined in the public condemnation.” That evening, when Mr. Clinton offered to send in a team of experts to help the country put together a national treatment plan, Mr. Mbeki took him up on it.

The Clinton Foundation helped devise a plan and mobilized 20 people to travel to South Africa in 2004 to help carry it out. But the South African government never invited them, Mr. Clinton said. So the foundation, which had projects all over Africa, was to have none in South Africa.

Changes since Mr. Mbeki’s fall from power have prompted many to hope for forceful South African political leadership on AIDS. Mr. Mbeki’s rival and successor as head of the party, Jacob Zuma, who is expected to become president after next year’s election, himself made a famously questionable remark about AIDS.

In his 2006 rape trial, in which he was acquitted of sexually assaulting a family friend, he testified that he sought to reduce his chances of being infected with H.I.V. by taking a shower after sex. Nonetheless, he seems to have more conventional views on the pandemic.

“Who would have thought Jacob Zuma would be better than Mbeki, but he is,” said Richard C. Holbrooke, the former ambassador to the United Nations in the Clinton administration who heads a coalition of businesses fighting AIDS. “The tragedy of Thabo Mbeki is that he’s a smart man who could have been an international statesman on this issue. To this day, you wonder what got into him.”

For South Africans who watched the dying and were powerless to stop it, the grief is still raw. Zackie Achmat, the country’s most prominent advocate for people with AIDS, became sick during the almost five years he refused to take antiretrovirals until they were made widely available. He cast Mr. Mbeki as the leading man in this African tragedy.

“He is like Macbeth,” Mr. Achmat said. “It’s easier to walk through the blood than to turn back and admit you made a mistake.”

A version of this article appears in print on , on Page A1 of the New York edition with the headline: Study Cites Toll Of AIDS Policy In South Africa. Order Reprints|Today's Paper|Subscribe